Both ER and Ob deliver: Who gets paid?

Melanie Witt,, RN, CPC, MAMs. Witt, former program manager in the Department of Coding and Nomenclature at the American College of Obstetricians and Gynecologists, is an independent coding and documentation consultant. Reimbursement Adviser reflects the most commonly accepted interpretations of CPT-4 and ICD-9-CM coding. When in doubt on a coding or billing matter, check with your individual payer.

Q An Ob patient presented to the emergency room (ER) in labor. The ER doctor immediately delivered the baby.

Labor and delivery staff had by then arrived. They took neonate and mom to the Ob suite, where I delivered the placenta and inspected and attended to the vagina.

The ER coded that their physician performed the “delivery,” using 59409 (Vaginal delivery only [with or without episiotomy and/or forceps]). They felt they would be out of compliance if they did not bill as such. I disagree. They took a large part of the Ob fee, and we were denied the payment for our complete obstetric care.

What should they have coded?

A The ER physician can certainly bill for delivering the baby, but this is not always done. Sometimes an agreement exists between the hospital and the attending physicians/Ob unit stating that any delivery performed by ER physicians will be billed by the attending obstetrician; compensation is then handled internally.

In this case, the ER physician may bill for delivery, but should have included modifier –52 to indicate a reduced service Code 59409 includes the delivery of the placenta (and episiotomy, if required), which the ER physician did not perform.

For your part, you have 2 coding options: You can bill for the global care, but add modifier -52 to 59400 (Routine obstetric care including antepartum care, vaginal delivery [with or without episiotomy, and/or forceps]). You’ll need to submit documentation indicating what part of the global care you did not perform. Here I would emphasize that the ER physician did not do labor management, delivery of the placenta, episiotomy, or any follow-up care—and that as such, the total amount for the delivery should not be deducted from your global fee.

Conversely, you can itemize the services you performed. This could consist of the following codes:

59426: seven or more antepartum visits (your fee will be the total for all visits)